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Naloxone Reporting Form

  1. Use of Naloxone During Emergency Drug Overdose

  2. Has person been treated with Naloxone by this agency in the past?*

  3. Location of Use / Location of Overdose

  4. Overdoser Information

  5. Gender

  6. Race / Ethnicity

  7. Overdose Signs / Symptoms Exhibited

  8. Actions Taken

  9. Was rescue breathing performed?

  10. Was AED utilized?

  11. Was CPR initiated?

  12. Did the overdoser survive?

      1. Additional Information

      2. Leave This Blank:

      3. This field is not part of the form submission.